Moderate Sedation: A depressed level of consciousness that carries the risk of losing protective reflexes. Sedation Criteria Includes:

ability to retain protective airway reflexes ability to independently and continuouslymaintain a patent airway

ability to respond appropriately to bothphysical and verbal stimuli

Objectives of Moderate/Conscious Sedation 1. Use the least amount of sedation to provide pt. comfort 2. Maintain adequate sedation with minimal risk 3. Relieve anxiety and produce amnesia 4. Provide relief of pain and other noxious stimuli 5. Enhance patient cooperation 6. Maintain stable vital signs 7. Ensure a rapid recovery

1.

Minimal sedation = anxiolysis (removal of anxiety)A drug-induced state which patients respond normally to verbal commands Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are unaffected.

2.

Moderate sedation/analgesia (Conscious Sedation)Patients respond purposefully to verbal commands, either alone or accompanied by light, tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate Cardiovascular function is usually maintained.

3. Deep Sedation/analgesia

Patients cannot be easily aroused, but respond purposefully following repeated or painful stimulation The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

4. Anesthesia

Consists of general anesthesia and spinal or major regional anesthesia General anesthesia is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation The ability to independently maintain ventilatory is impaired Positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function Cardiovascular function may be impaired

Moderate Versus Deep SedationModerate Mood altered. Purposeful response to verbal

Deep Sedation Cognitive function impaired Patients cannot be easily aroused Respond purposefully following

commands Respond to verbal commands alone or with light tactile stimulation Patient cooperative Can maintain own airway Spontaneous ventilation is adequate VS stable

accompanied by repeated or painful stimulation Not awake enough to follow verbal commands Ability to maintain own airway Ventilatory function may be impaired Cardiovascular function is usually ok VS may be labile

Indications for Sedation1. 2. 3.

Diagnostic procedures (angiogram, endoscopy, biopsy) Minor Surgery (skin closure/excision) Potentially painful procedures (chest tube insertion or fracture reduction)

4. Decrease anxiety before procedures and diagnositc tests

(MRI)

Who can administer Moderate SedationOnly qualified staff may administer moderate sedation under the guidance and order of a credentialed physician on the facility s medical staff.

Pre Procedure AssessmentPhyscian: 1. The physician reviews with the patient, parent, guardian: The risks, options, and benefits of the selected medications and procedure. Obtains informed consent, which is kept in the patient s medical record.(the nurse may witness the signature on the consent) Writes order on chart for medications to be given for the procedure.

Physician Admission AssessmentAn admission assessment will be completed preprocedure. The physician s assessment should include documentation of, but not limited to, the following ASA Classification Status Mallampati Scale Appropriateness of moderate sedation for the patient

American Society of Anesthesiology / ASA ClassificationA.S.A. Class 1: No organic, physiologic, biochemical, or psychiatric disturbance. The pathologic process for which the operation is to be performed is localized and does not entail a systemic disturbance. A.S.A. Class 2: Mild to moderate systemic disease disturbance cause either by the condition to be treated surgically or by other pathologic processes: well-controlled hypertension; and no postural hypertension history of asthma, no wheezing on day of procedure anemia; Hct greater or equal to 30 gm cigarette use; without COPD problems well-controlled diabetes mellitus; mild obesity; 20% above ideal body weight (IBW) age 70 years; and pregnancy.

ASA Level Cont.A.S.A Class 3: Severe systemic disturbance of disease from whatever cause, even though it may not be possible to define the degree of disability with finality: angina; status post-myocardial infarction; less than 3 months ago poorly controlled hypertension; symptomatic respiratory disease (e.g., asthma, COPD); and massive obesity, greater than 50 pounds or 30% of IBW) A.S.A. Class 4: Indicative of the patient with severe systemic disorders that are already life threatening, not always correctable by operation: unstable angina, unrelieved by Nitroglycerin and rest congestive heart failure; debilitating respiratory disease; and hepatorenal failure.

ASA Level Cont. A patient classified as ASA 1 and 2 will be sedated and

monitored by RN staff. A patient classified as ASA 3 and 4 may be sedated and

monitored by an RN under the direct supervision of an anesthesiologist or a physician credentialed to give IV conscious sedation.

Mallampati SystemThe Mallampati system anticipates the degree of difficulty of endotracheal intubation from I to IV, by relating tongue size to pharyngeal size. Patient is examined in the sitting position, with head in neutral position and mouth open 50-60mm (2-21/2 inches) and the tongue protruding to the maximum.

Mallampati System Cont.

Characteristics of Potential Difficult AirwayThe following physical characteristics may indicate the potential for difficult airway management: Hyponathic jaw (recessed) Hypernathic jaw (protruding) Deviated trachea Large tongue Short thick neck Protruding teeth High arched palate

Pre-procedure AssessmentNurses: An admission assessment will be completed pre-procedure. The assessment will include documentation of, but not limited to, the following: a) allergies/sensitivities; b) current medications; c) baseline vital signs and weight; d) IV site and patency; e) Concurrent medical problems; f) Level of consciousness.

Pre-procedure Assessment Cont.Physical baseline assessment parameters include all the above and: Anxiety level Vital signs include temperature Skin color and condition Sensory defects Relevant medical and surgical history, including substance abuse Patient perceptions regarding procedure and moderate sedation

Nurse Cont.dentist office problem with the sedation or to the local? Identify current medications - check for contraindications i.e. you don't want to give narcotics when your patient is taking MAO Inhibitors, or if asthmatic avoid Fentanyl. Obtain weight - precalculate dosages for sedatives and reversal agents Medical Condition unrelated to this procedure is it well controlled? What is patient s perception of their pain tolerance ? i.e. use scale 1-10 to establish baseline pain level NPO status (Remember that emergency patients given sedation are at high risk for aspiration.) Ask if they have ever had a bad experience in surgery or

Nurses Cont.Patient Education: Concurrence with pre-arrangements for safe transportation including discharge to the care of a responsible adult. The patient may not drive theirself home. Educate the patient what to expect during the procedure, and the continuous monitoring. Demonstrate what correct "deep breathing" looks like. Instruct the patient in the use of a pain scale (e.g. 1-10 pain scale) Provide discharge instructions prior to the procedure whenever possible; postsedation the patient may not remember everything that is said to them. Ensure emergency equipment, medications, and supplies are immediately available.

Equipment NeedsEmergency equipment, including a defibrillator, must be immediately accessible to every location where conscious sedation is administered. The equipment should include, but not be limited to the following: emergency, resuscitation, and antagonist drugs; airway and ventilator adjunct equipment for adult and pediatric patients; defibrillator; source for administration of 100% oxygen and capability for suctioning of the patient.

Patient AssessmentCardiovascular status - HR, BP Goal: Back to patient s baseline or within +/- 20% of patient s baseline. Respiratory status - Oxygen saturation, respiratory rate, pattern Goal: > 94% on room air or back to patient s baseline levels Level of Consciousness Goal: Alert/awake or at baseline Neurological/Activity Goal: Back to baseline

Patient Assessment Cont.Pain Assessment: Goal: < 4 or back to baseline (use 1-10 pain scale; 1= minimal) GI assessment: Goal: No Nausea or Vomiting Protective Reflexes include Subconscious abilities of a person to swallow secretions and prevent foreign bodies (emesis) from entering the lungs via aspiration or coughing, Eyes blink Extremities move purposefully Speaking with minimal slurring.

Intraprocedural Assessment The patient will be connected to all monitors upon

arrival in the procedure area. Monitor connections will be reassessed following any position changes before or during the procedure. All monitor alarms will be active and audible throughout the procedure. All patients with an SaO2 < a certain level (e.g. 94%) will receive supplemental nasal cannula oxygen as ordered by the physician.

Intraprocedural Assessment

All patients receiving conscious sedation will be continually monitored for physiological changes. Monitoring will be documented every 5 minutes or at each significant event on the appropriate monitoring record for each area. This monitoring procedure may include, but is not limited to, the following: monitoring devices or equipment used; physiological data from continuous monitoring (cardiac rate and rhythm, oxygen saturation, respiratory rate, blood pressure);

1. 2.

3. 4. 5. 6. 7.

level of consciousness; dosage, route, time and effects of all drugs or agents used; type and amount of fluids administered; any untoward or significant patient reaction and its resolution; and skin condition and color (warm cool, pink, pale, cyanotic).

Medications*Each and Every patient under going Moderate Sedation must have IV Access. The medications used for moderate sedation are chosen with consideration to: Action Length of action Bioavailability !!! Be careful with how fast you give drugs IV push. Some medications can cause serious side effects if given too rapidly.

Benzodiazepines Midazolam (Versed) Diazepam (Valium)

1. Produce sedation, relief of anxiety, antegrade amnesia, and some skeletal muscle relaxation but not pain relief 2. Synergistic (additive) effect when given with narcotics 3. Use with caution in patients with: a history of COPD, sleep apnea, known cardiovascular depression, intoxicated patients, patients with liver or renal disease, difficult airways, and in the very young and the very old

Benzodiazepines Cont.Antagonist = Flumazenil (Romazicon) Age-Related Considerations: In the elderly patient reduce the loading dose by 40-50% Avoid use in pregnancy crosses placental barrier and is in breast milk Watch for symptomatic bradycardia if your patient is on: Lopressor (metoprolol) or Inderal (propanolol) or Digoxin (digitalis) Increase effect of action for patients on: CNS depressants Skeletal muscle relaxants MAO inhibitors/tricyclic antidepressants Antiarrhythmics (e.g. lidocaine) Concurrent sedatives/narcotics Alcohol Antipsychotics Phenothiazines/antihistamines

Benzodiazepines Cont.Diazepam (Valium): Minimal effect on ventilation and circulation Long acting When given IV: Rate for IVP = 5 mg/minute Onset = 1-3 minutes Peak effect in 3-4 minutes Duration = 15-30 minutes Interaction / Toxicity: Don't give IM Bradycardia, hypotension, respiratory depression, drowsiness, ataxia, confusion, depression, venous thrombosis/phlebitis at injection site Return of drowsiness may occur in 6-8 hours after dose Do not mix or dilute with other solutions / drugs

Benzodiazepines Cont.Midazolam HCL (Versed): Short acting, with sedative and skeletal muscle relaxing properties Compared with Diazepam (Valium) it is more rapid onset, shorter duration, greater amnesic effect, and 3-4 times as potent . If given IV: Rate if given IVP = 1 mg/minute; Give slow IVP, never rapid as IV bolus respiratory depression &/or arrest may result from excessive dosing Onset = 1-5 minutes Peak = 3-5 minutes Duration = 30-40 minutes; up to 2-4 hours Interactions/Toxicity: Tachycardia, PVC, hypotension, broncho/laryngospasm, apnea, tonic-clonic motion Reduce dose in elderly, hypovolemic, and COPD Contraindicated in glaucoma unless patient is being treated for it

Narcotics (Opioids) Morphine Sulfate (MS) Meperidine (Demerol) Fentanyl (Sublimaze) Analgesia (pain relief ) properties are the best of

any drug Profound effect on the cardiovascular system Morphine and Demerol effect the respiratory system leading to bronchoconstriction, decreased respiratory rate and volume

Narcotics (Opioids) Cont.Agonist = Naloxone (Narcan) Age-Related Considerations: Elderly patients usually require reduced dose Narcotics cross the placental barrier and are secreted in breast milk Increased effects of narcotics are seen with: CNS depressants Skeletal muscle relaxants MAO inhibitors Cimitidine (Tagamet) Concurrent sedatives Alcohol Antipsychotics Phenothiazines/antihistamines

Narcotics (Opioids) Cont.Demerol (Meperidine) : All narcotics but Demerol (meperidine) produce bradycardia (Demerol produces tachycardia secondary to its vagolytic effect); use with caution if liver or renal disease, or MAO inhibitor use. Slightly less potent then Morphine; however half-life = 15-30 hours May give postoperatively to decrease shivering. If given IV: IV inject rate = 25 mg/minute; may cause vomiting if given too rapidly. Onset = 5-10 minutes Peak : 15 minutes Duration = 2-3 hours

Narcotics (Opioids) Cont.Fentanyl (Sublimaze): As analgesia, Fentanyl is 75-125 times more potent than Morphine (e.g. 100 micrograms of Fentanyl = 10 milligrams of morphine) Incompatible in IV tubing with Valium (remember - nothing goes with Valium) If given IV: IV Inject rate = 50 mcg/minute; if given too rapidly may get wooden chest ; chest wall muscles become tight; treat by ventilating with an Ambu-bag and a muscle relaxant (i.e. succinycholine) Onset within 30 seconds Peak effect = 5-15 minutes Duration = 30-60 minutes Interaction/Toxicity: Analgesia enhanced and prolonged by epinephrine and clonidine

Narcotics (Opioids) Cont.Morphine (MS) : Morphine is inexpensive Side effects markedly increased if rate of injection too rapid (i.e. respiratory depression) Pain relief is almost immediate and lasts up to 4-5 hours (average 2 hours) Incompatible in IV tubing with Demerol and other meds. If given IV: IV inject rate = 2-5 mg/minute Onset = 1-3 minutes Peak: 20 minutes Duration = 4 hours

Reversal MedicationsNaloxone (Narcan) Flumazenil (Romazicon) Give in small doses to reverse deep sedation and respiratory depression. Some physicians order a reversal agent to rapidly reverse the effects of sedation. Reversal medications length of action is shorter than the length of the drug reversed, so repeat dosing of the reversal drug may be necessary. If a patient receives a reversal agent, that patient should be monitored for 2 hours prior to discharge, and then only discharge if they meet discharge criteria.

Reversal Medications Cont.Naloxone (Narcan) Narcotic antagonist, reverses respiratory depression and analgesia due to opioids. May be given IV push, IM or Subcutaneous injection for injections if using dilution (shown below) then administer in divided doses. Onset: IV = 2-3 min. IM = 15 min. Subcutaneous = 15 min. Dilute 0.4mg/ml Narcan with 9 ml injectable normal saline (= 0.04mg Narcan/ml or 40mcg/ml) This dose works for all pediatric patients over 4kg (8.8 pounds): Pediatric IV, IM, Subcutaneous dose: 0.01mg/kg every 2-3 minutes Adult IV, IM, Subcutaneous dose: 40 mcg or 1ml every minute, not to exceed 0.1-0.2 mg every 2-3 minutes

Reversal Medications Cont.Narcan cont. Onset: 1 2 min. Peak: 5-15 minutes Lasts: 45 min. 4 hours Often does not last as long as opioid and therefore may need to repeat dose. Adverse effects: Reverses analgesia (pain control) Titrate to effect if given rapidly can produce noncardiogenic pulmonary edema tremors, excitement, seizures, hyperventilation, pulmonary edema (noncardiogenic), hypotension, bradycardia, ventricular tachycardia/fibrillation, nausea/vomiting Contraindications: Patients with a history of hypersensitivity to the drug.

Reversal Medications Cont.Romazicon (flumazenil) Pediatric (age 1 to 17 yrs.) IV dose: 0.005-0.01 mg/kg every 2-3 minutes based on response; Maximum dose for reversal of moderate sedation is 0.2 mg. Adult IV dose: 0.003 mg /kg every 1-2 minutes as needed; Maximum dose for reversal of moderate sedation is 0.2 mg Use free flowing IV. May repeat in 2-3 minute intervals in doses of 0.2 mg up to desired level of consciousness. Do not exceed total dose of 3 mg/hr without response. Onset: 1-2 min. Peak: 6 10 min. Lasts: 1- 2 hours 80% of the response within the first 3 minutes; no response in 5 min. look for another cause. Adverse effects: dizziness, headache, agitation, seizures, dyspnea, sweating, palpitations, dysrhythmias, hypertension, chest pain, nausea/vomiting, pain at injection site. Contraindications: Hypersensitivity to flumazenil or benzodiazepines can precipitate withdrawal or seizure activity. May provoke panic attack in patient with history of panic disorder, unknown coma, physical dependence on benzodiazepines.

Local AnestheticsLidocaine 0.5-2 30-120 120-360 300 500 (Xylocaine) Rapid Moderate Bupivicaine 0.25-0.5 120-240 180-420 175 225 (Marcaine) Slow High High (Note: 2% concentration is more potent than the 1% )

Local Anesthetics Cont.Progressive Signs of Toxicity LOCAL Anesthetics: 1. Metal taste in mouth 2. Tinnitus ringing in the ears 3. Peri-oral numbness/tingling lips are numb 4. Change in sensation talk nonsense, euphoria 5. Seizure 6. Respiratory Arrest or 7. Cardiac Arrest

Local Anesthetics Cont.Toxicity Treatment: Remember CPR A-B-Cs Oxygen support respiration with AMBU bag Ventilator Seizure give Valium, Versed, Diprivan (Propofol) ACLS protocols are followed for cardiac arrest

AgitationSome patients will become agitated during Moderate/Conscious Sedation and you will want to rule out the cause. The top 4 (four) causes are: 1. Hypoxia (oversedation) - < 94% oxygen saturation 2. Inadequate Analgesia remember to time the administration of the medication to achieve peak effect during the procedure. 3. Inadequate Sedation titrate slowly to patient response, never bolus 4. Paradoxical Reaction rare

Airway ManagementRecognizing a patient who has an inadequate airway: Change in breathing (snoring, loss of snoring) Decreased oxygen saturation Loss of chest expansion Rocking of the chest and abdomen Changes in heart rate or blood pressure Changes in mental status; increased difficulty in arousing, agitation Changes in skin color from pink to pale or dusky a late sign of hypoxemia Changes in head position Any sign of a change in the patient s general status should initiate an inspection of respiratory status -- restlessness and agitation are always considered signs of hypoxia or if not that then inadequate analgesia.

Airway Management Cont.Hypoxemia is generally a late sign of hypoventilation or airway obstruction Remember gradual hypoxemia may not produce any signs or symptoms Intervene for your patient: 1.) Ask your patient how they are doing, if they respond and deny any respiratory problems, then one can be reasonably certain that the airway is patent. 2.) If a patient does not respond, then gentle stimulation should be tried such as shaking a shoulder and using a louder voice.

Airway Management Cont.3.) If a patient has not yet responded try moving the patients tongue off the back of their throat by first: turning head laterally, then head-tilt / chin-lift, then a jaw-thrust maneuver will also serve to stimulate the patient to breathe because it is somewhat painful when used. The jaw thrust = use of both hands behind the ramus of the mandible to move the mandible forward to lift the tongue off the back of the throat to open the airway. Be aware that the facial nerve runs behind the ramus of the mandible and damage to it can result in facial palsy.

Airway Management Cont.Nasal Airway - First try to insert a nasal airway because nasal are better tolerated than oral airways if your patient is not unconscious. Measure for length from the tip of the nares to the lobe of the ear. Lubricate the tube first with KY jelly (or any water-soluble jelly), and insert in the nostril staying close to the midline until it sets behind the tongue. Slight rotation of the tube may help you angle it through as needed. Gentle pressure not force may be used. If excessive pressure is encountered on placement of the airway, withdraw and attempt to place it on the other side. Check lung sounds immediately after putting it in. RISK: Epistaxis down the back of the throat may stimulate laryngospasm or bronchospasm

Airway Management Cont.Orophyaryngeal (oral) Airway may work safest for unconscious patients because it may stimulate vomiting. 1) Measure from corner of mouth to tip of ear to estimate length. 2) Suction before insertion if possible. 3) Insert with curve up as it enters the mouth, as you reach the back of the throat 4) rotate it so it curves down the throat or use a tongue depressor and insert the airway curve down. 5) Listen to lung sounds after insertion.

Airway Management Cont. Oral airway risks = may stimulate vomiting, cause

bradycardia due to vagal stimulation, retching leading to hypertension and tachycardia, laryngospasm, dental damage, and lip lacerations - also ensure that lips or tongue are not trapped between teeth.

Airway Management Cont.Ambu-bag = positive pressure ventilation bag-valvemask device Ambu-bags usually need 10-15 liters of oxygen to provide 100% oxygen. If your patient is breathing: inefficiently, but not completely apneic, then synchronize your bagging with the patient's inspiration effort. not at all on their own, bag at a rate of 16-20 breaths a minute or every 3-5 seconds.

Airway Management Cont.If basic airway maneuvers fail to provide a patent airway with adequate air exchange or if the patient has limited respiratory efforts, the physician supervising the procedure should consider administering reversal agents Prepare for intubation with an endotracheal tube.

Airway Management Cont.Supplemental Oxygen: Nasal Cannula: 1-6 L/minute = 24 - 44 % for patient with normal tidal volume 1 L = 24% 3 L = 32% 5 L = 40% 2 L = 28% 4 L = 36% 6 L = 44% Face Mask: 8-10 L = 40 - 60%, the flow should be >5 L / minute to avoid rebreathing exhaled air held inside the mask. Ambu-bag: 15 L = up to 100%, use basic airway head positioning and oropharyngeal airway if possible. Hold mask to patients face and squeeze the bag. Watch for gastric distention.

Postprocedure ComplicationsPain Postprocedure pain Pain from chronic condition(arthritis, etc.) Treatment Options Acetaminophen NSAIDs Prescribed opiates

Postprocedure ComplicationsNausea and Vomiting Increased vagal tone Hypotension Pain Opiate administration Hypoglycemia from NPO status Treatment Options Liberal IV fluid replacement Phenergan (Promethazine) Zofran (Ondansetron) Compazine

Postprocedure ComplicationsAirway obstruction Tongue against posterior pharynx Secretions Vomit Blood Treatment Options Verbal / physical stimulation Head tilt Chin Lift Jaw Thrust Nasal / Oral Airway Intubation

Postprocedure ComplicationsHypoventilation Residual sedative effects Preexisting pulmonary disease Inadequate reversal Overdose Treatment Options Verbal / physical stimulation Continue giving oxygen Encourage deep breathing Give additional reversal agent Assisted ventilation If not breathing - intubate

Postprocedure ComplicationsHypotension Enhanced vagal tone Left ventricular dysfunction Hypovolemia Pain Hemorrhage Treatment Options Reduce factors that stimulate Vagal tone (pain, anxiety, agitation, etc.) Correct factors that impair left ventricular performance (myocardial ischemia, fluid overload, etc.) IV fluids Pain relief Ephedrine, Trendelenburg

Postprocedure ComplicationsHypertension Neuroendocrine response to procedural pain Hypoxemia Hypercapnia Preexisting hypertension Treatment Options Relieve pain Relieve noxious stimuli (full Bladder distention bladder) Fix respiratory obstruction Give beta / alpha blockers

Criteria for Discharge1. All parameters normal or back to patient s baseline. 2. Physician MUST give a discharge order 3. Oxygen saturation > 94% on room air or equal to patient s pre-sedation state 4. Adult patients must be able to ambulate independently (or at baseline) - except for patients whose procedure changes their ability to ambulate. 5. Infant and toddler patients must be able to sit up independently or walk as is appropriate for age.

Criteria for Discharge6. The patient should have no more than minimal/manageable discomfort 7. REACT Score discharge score = pre-procedure status or higher; (if score is less than 7) 8. Stability of vital signs, including temperature. 9. Pre-procedure level of consciousness 10. Intact protective reflexes, including a gag reflex 11. Ability to retain oral fluid, as appropriate to physician orders 12. Ability of patient and home care provider to understand home care instructions

Discharge Instructionsdangerous machinery for 24 hours or longer if taking pain or sedating medication Do NOT drink any alcohol for 24 hours Diet Instructions Wound care / Dressing changes Explain follow up phone calls or surveys that the patient might get If medications are given - the purpose, dose, route, frequency, duration of use, and side effects if any should be explained Written discharge instructions will be given to all patients: Telephone number patient can call for assistance if needed Tell them the name of the sedating drug used Instructions to NOT drive a motor vehicle or operate any

The End